2 Dor Neonatal: os efeitos da anestesia“agentes anestésicos ou analgésicos são desnecessários na cirurgia de fechamento do canal arterial”Lippmann, Ligation of patent ductus arteriosus in premature infants. Br. J. Anaesth. 48:“59% das enfermeiras acreditam que neonatos não sentem dor da mesma forma que adultos”Franke, L., C. Lurid, and A. Fanaroff A national survey of the assessment and treatment of pain in the newborn intensive care unit (abstract). Pediatr. Res. 20:347A.Twenty-four neonates at weeks' gestation with a weight range of g underwent ligation of patent ductus arteriosus (PDA). The infants had mild to severe respiratory distress syndrome at birth and later developed signs of heart failure as a result of left-to-right shunting through a PDA. Surgical closure of the PDA was performed within 2-31 days after birth. In the period before operation the heart rate was monitored constantly and the arterial blood-gases were assessed frequently. The trachea was intubated and respiration was controlled with a ventilator. Surgery was performed under controlled ventilation and no anaesthesia was used. Care was taken not to overventilate the lungs. Nine infants died. Death was associated with higher peak inspiratory ventilator pressures at the time of operation and with complications occurring during or after the operation. The most common complication was tension pneumomediastinum which appears to be related to excessive ventilator pressures during surgery Br J Anaesth Apr ;48 (4):365-9Twenty-four neonates at weeks' gestation with a weight range of g underwent ligation of patent ductus arteriosus (PDA). The infants had mild to severe respiratory distress syndrome at birth and later developed signs of heart failure as a result of left-to-right shunting through a PDA. Surgical closure of the PDA was performed within 2-31 days after birth. In the period before operation the heart rate was monitored constantly and the arterial blood-gases were assessed frequently. The trachea was intubated and respiration was controlled with a ventilator. Surgery was performed under controlled ventilation and no anaesthesia was used. Care was taken not to overventilate the lungs. Nine infants died. Death was associated with higher peak inspiratory ventilator pressures at the time of operation and with complications occurring during or after the operation. The most common complication was tension pneumomediastinum which appears to be related to excessive ventilator pressures during surgery Br J Anaesth Apr ;48 (4):365-9

9 Figure 1. Changes in plasma epinephrine and norepinephrine concentrations across timeThere have been significant changes in the management of neonates and infants undergoing cardiac surgery in the past decade. We have evaluated in this prospective, randomized, double-blinded study the effect of large-dose fentanyl anesthesia, with or without midazolam, on stress responses and outcome. Forty-five patients < 6 mo of age received bolus fentanyl (Group 1), fentanyl by continuous infusion (Group 2), or fentanyl-midazolam infusion (Group 3). Epinephrine, norepinephrine, cortisol, adrenocortical hormone, glucose, and lactate were measured after the induction (T1), after sternotomy (T2), 15 min after initiating cardiopulmonary bypass (T3), at the end of surgery (T4), and after 24 h in the intensive care unit (T5). Plasma fentanyl concentrations were obtained at all time points except at T5. Within each group epinephrine, norepinephrine, cortisol, glucose and lactate levels were significantly larger at T4 (P values < 0.01), but there were no differences among groups. Within groups, fentanyl levels were significantly larger in Groups 2 and 3 (P < 0.001) at T4, and among groups, the fentanyl level was larger only at T2 in Group 1 compared with Groups 2 and 3 (P<0.006). There were no deaths or postoperative complications, and no significant differences in duration of mechanical ventilation or intensive care unit or hospital stay. Fentanyl dosing strategies, with or without midazolam, do not prevent a hormonal or metabolic stress response in infants undergoing cardiac surgery.Implications: We demonstrated a significant endocrine stress response in infants with well compensated congenital cardiac disease undergoing cardiac surgery, but without adverse postoperative outcome. The use of large-dose fentanyl, with or without midazolam, with the intention of providing "stress free" anesthesia, does not appear to be an important determinant of early postoperative outcome.Gruber, E. M. et al. Anesth Analg 2001;92:

10 Diferenças entre os estudos de Gruber e AnandNo estudo de Eva Gruber houve elevação dos níveis de cortisol durante a cirurgia,enquanto Anand observou uma redução nos níveis de cortisol no grupo sufentanilAnand demonstrou um aumento entre 0,5 e 1 x nos níveis de epinefrina, enquanto no estudo Gruber, a epinefrina aumentou 8 x no Grupo 1, 12 x no Grupo 2 e 15 x no Grupo 3Direct comparisons between the two studies clearly are not possible. In the earlier study, patients in were younger (mean age, 5.3 days), the diagnoses, surgical procedures, and bypass techniques were different (e.g., 15 of 45 patients underwent a Stage I repair for hypoplastic left heart syndrome), and a larger circuit prime volume and different laboratory assays were used to measure the neuroendocrine response (2). The magnitude of the change in neuroendocrine response may also be different between the two studies, particularly as the original study included neonates managed in the ICU before surgery. Further, sufentanil was used in the early study whereas fentanyl is currently more commonly used in our institution for congenital cardiac surgery. At equipotent doses (5–10:1 ratio), sufentanil and fentanyl have a similar pharmacodynamic profile and stress hormone release during cardiac surgery (3,17,18). In contrast, one study involving adult volunteers suggested that sufentanil may have an increased affinity for the µ1 receptor compared with fentanyl (19), although there are no data to support this in pediatric patients. The total bolus dose of sufentanil used in the early study (total 30 µg/kg) is relatively larger than the total bolus dose of fentanyl used in this study (100 µg/kg), which may account for the smaller increase in epinephrine levels in the early study (2).

18 Roberts, K. D. et al. Pediatrics 2006;118:1583-1591FIGURE 2 Time resultsThe purpose of this work was to investigate whether using a muscle relaxant would improve intubation conditions in infants, thereby decreasing the incidence and duration of hypoxia and time and number of attempts needed to successfully complete the intubation procedure. PATIENTS/METHODS: This was a prospective, randomized, controlled, 2-center trial. Infants requiring nonemergent intubation were randomly assigned to receive atropine and fentanyl or atropine, fentanyl, and mivacurium before intubation. Incidence and duration of hypoxia were determined at oxygen saturation thresholds of < or = 85%, < or = 75%, < or = 60%, and < or = 40%. Videotape was reviewed to determine the time and number of intubation attempts and duration of action of mivacurium. RESULTS: Analysis of 41 infants showed that incidence of oxygen saturation < or = 60% of any duration was significantly less in the mivacurium group (55% vs 24%). The incidence of saturation level of any duration < or = 85%, 75%, and 40%; cumulative time > or = 30 seconds; and time below the thresholds were not significantly different. Total procedure time (472 vs 144 seconds) and total laryngoscope time (148 vs 61 seconds) were shorter in the mivacurium group. Successful intubation was achieved in < or = 2 attempts significantly more often in the mivacurium group (35% vs 71%). CONCLUSIONS: Premedication with atropine, fentanyl, and mivacurium compared with atropine and fentanyl without a muscle relaxant decreases the time and number of attempts needed to successfully intubate while significantly reducing the incidence of severe desaturation. Premedication including a short-acting muscle relaxant should be considered for all nonemergent intubations in the NICU.Roberts, K. D. et al. Pediatrics 2006;118:Ensaio clínico controlado e randomizado comparando atropina e fentanylcom atropina, fentanyl e mivacurium